Monthly Archives: December 2013

I’ve been hearing about JNC 8 for so long, that I thought it didn’t really exist. Thanks to some persistent hypertension experts, it is here at long last. Here’s a quick review of the major points. I’m sure that we will see some commentary in the days and weeks to come, I’ll try to keep you updated on that as well. I’d love to hear what you think- start the conversation in the comments below.

Higher BP targets

We are used to aiming for 140/90 for most people, and 130/80 for those with CKD, diabetes, CAD, and other comorbidities. But new evidence has emerged that these may not be so great, particularly for elderly patients. So JNC 8 says- Adults 18-60 (even with DM or CKD) should aim for BP <140/90. We can be a little more relaxed with patients over 60, and aim at 150/90 for them, so long as they don’t have CKD or DM. Most of this change comes because there really was no outcome data for our prior target, and it seems that getting people to the 140s systolic provides just as much benefit as the 130s range.

Relaxed first line medicine choices

We’ve known that this was coming for a while. JNC 7 recommended thiazides as first line for all, but there was never any real data to back that up. So JNC 8 says that we can use thiazides, ACE-I/ARBs, or calcium channel blockers as a first choice for most patients. They do acknowledge the racial difference in response to ACE inhibition, and recommend that we DON’T use ACE/ARB as first line for our black patients. EXCEPT (there’s always an exception) that for patients with chronic kidney disease (but not necessarily diabetes without ckd), use ACE-I first, no matter the race.

Second, and third, and fourth line medicines

Really not much different here, except there are not really recommendations about when to start two medicines at first visit. JNC 8 says we can pick a variety of treatment strategies– maximize one medicine at a time, add a second agent before maximizing the first, or start two medicines at once. When you add agents; pick from that first line list (thiazides, ACE/ARB, CCB) until you’ve used them all, then use aldosterone antagonists, beta blockers, central agents, or other vasodilators. They do recommend avoiding ACE-I and ARB combos for most patients.

What’s Missing

JNC 7 discussed prehypertension, secondary hypertension, resistant hypertension, adherence, how to measure blood pressure, and lots of other related issues. The JNC 8 group just picked 3 questions that they felt were most important: does starting treatment at a particular threshold improve outcomes, does a particular treatment goal improve outcomes, do various drugs have important differences in risk/benefit calculation and outcomes. Very evidence based and outcome oriented, which is kind of refreshing.

What about my patients now?

For all of us who have been trying to follow JNC 7 (and the subsequent performance measures created from that guideline), should we go adjusting therapy on our patients to meet new targets? No, say these experts. If your patient has a blood pressure of <150/90 on their current therapy, and is doing well, no need to change. Stay tuned to see if any of our performance targets change.

A great big picture algorithm from the JNC 8 group is here, and the link to the guidelines themselves is here (on the JAMA website subscription may be needed).

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We have been doing wet preps a plenty in resident clinic lately, and I find myself reviewing the same info. That’s sounds like a good reason for a blog post! I’ve organized by diagnosis below, with history, PE, and wet prep clinical pearls.

Bacterial Vaginosis (40-45% of vagnitis)

HX: profuse discharge, thin, watery. Worse after menses or after intercourse. May be foul-smelling. Usually not painful, pruritic.

PE: Cup of milk

Wet Prep: Clue cells. Which is one of those things that is easy to say, but hard to describe. Here’s a picture of normal squamous epithelial cells, followed by clue cells.

Cell borders are smooth, cytoplasm is clear, except for the nucleus.

Cells look “dirty”- cytoplasm is not so clear and the borders are irregular. In reality, the cytoplasm is the same, but bacteria are all around the outside of the cell.

Trichomonas (15-20%)

PE: Strawberry cervix is the board question, but it is rare. More often you see the discharge (it’s thin and yellowish), and the cervical mucosa is red, friable.

Wet Prep: Trichomonads. Best way to see these is to look at the edges of the sample, and just leave the slide in one place for a while. Trich cells are more round/oval and smaller than the irregular shaped squamous cells. If you are patient, you can often see something moving – might just be the flagella moving, or you might notice the whole cell slowly moving against the flow of the rest of the liquid on the slide.

Cervicitis (GC, Chlamydia)

HX: discharge is similar to Trichomonas, thin and watery but with associated symptoms of pain/pruritus/dysuria. If systemic sx: nausea, fever, abdominal pain- think PID.

Wet Prep: Normal looking squamous cells, may see lots of white cells (smaller, less clear cytoplasm) in the background.

If you are more of a table person, here’s most of the info above in handy chart form.

Disease

History

Wet Prep

Pearls

Bacterial Vaginosis

Profuse Discharge, not painful/pruritic

Clue Cells

Women live with this for months before presenting. Worse after menses, intercourse

Candidiasis

Thick, white adherent discharge

Normal cells, but use KOH to identify Hyphae

If you see this, can skip the wet prep

Trichomonas

Combo of above- thin watery discharge, also painful/pruritic

Normal, but with white cells/trichomonads

Foul smelling discharge (even without the KOH)

Cervicitis

Similar to Trich, friable and painful cervix

Lots of white cells

May be GC, Chlamydia, Trich, HSV, others. (always test for other STIs)

Did you know that we have a dropbox for pocket cards? This is so that you can keep them all in your pocket (on your phone). I’ll put the chart below there. If you want a link to the dropbox, send me an email or comment below and I’ll hook you up. Another benefit to reading I Hate Rashes!

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Thanks to Michael Harmon for developing this awesome review of conjunctivitis for AMR, AND agreeing to let me put it up for all to see. That is kind of the point of this blog- share some of the great ambulatory teaching that is going on throughout the residency program with everyone.
If you want to be a guest poster too, it’s easy. Just shoot me an email and we’ll make it happen.

Images from visual DX.

Conjunctivitis

By Michael Harmon

Bacterial

Bugs: Staph aureus is common in adults. Strep pneumo, H. Influenza, and Moraxella catarrhalis are common in kids. Think pseudomonas if a contact wearer

Hyperacute bacterial conjunctivitis is usually secondary to N. gonorrhoeae. Often have concomitant urethritis. Requires hospitalization

Presentation: Usually unilateral conjunctival injection with thick discharge that reappears within minutes. Eye matting is a non specific finding also seen in viral/allergic

Treatment: Usually self limited but treatment can decrease course.

1st line erythromycin ointment or polymyxin/trimethoprim gtts for 5-7 days

2nd line fluoroquinolones (contacts) or azithromycin

Course: Should see improvement in 1-2 days Send to optho if no improvement